MEDICAL HISTORY · MEDICAL HISTORY Please mark YES or NO and fill in appropriate blanks as needed Kidney Disease Chronic Kidney Disease Yes No If yes, year diagnosed _____ Previous

MEDICAL HISTORY

Please mark YES or NO and fill in appropriate blanks as needed

Kidney Disease

Chronic Kidney Disease Yes No

If yes, year diagnosed __________________

Previous Nephrologist ___________________________________________

Transplant Yes No

If yes, date __________________

Donor type Living Deceased

Related Unrelated

Frequent Infections Yes No

Polycystic Kidney Disease Yes No

Any other kidney history we should know?

Diabetes

Do you have Diabetes? Yes No

If yes, type? Type 1 Type 2

Medication taken Insulin Oral Both

Last HgbA1C _____________________

Who manages your diabetes? _______________________________________

High Blood Pressure

High blood pressure? Yes No

If yes, year diagnosed? ___________________

Monitored at home? ___________________

Average reading? _________ / _________

Who manages BP? ___________________

EENT

Blindness Yes No Hearing Problems Yes No

Cataracts Yes No Glaucoma Yes No

Patient Name: __________________________________ Patient DOB: __________________

Heart

Heart Disease Yes No AICD Yes No

Atrial Fibrillation Yes No Valvular Disease Yes No

Pacemaker Yes No Congestive Failure Yes No

High Cholesterol Yes No Mitral Valve Prolapse Yes No

Irregular Heartbeat Yes No Murmur Yes No

If yes to any, who manages your heart disease? _____________________________________

Have you ever had cardiac surgery? Yes No

Respiratory

COPD Yes No Pneumonia Yes No

Chronic Bronchitis Yes No Tuberculosis Yes No

Asthma Yes No Sleep Apnea Yes No

Emphysema Yes No Pulmonary Yes No Hypertension

Do you use a C-PAP? Yes No

Do you wear chronic oxygen? Yes No

Do you see a lung doctor? Yes No

If so, who? ___________________________________________________

Gastrointestinal (GI)

GERD Yes No

Inflammatory Bowel Disease Yes No

Stomach/Bowel Ulcers Yes No

Irritable Bowel Syndrome Yes No

Gallbladder Disease Yes No Gluten Intolerance Yes No

Hepatitis Yes No Lactose Intolerance Yes No

Had a Colonoscopy? Yes No If yes, year? _____________________

Had an Upper Endoscopy? Yes No If yes, year? _____________________

See a stomach doctor? Yes No If so, who? ______________________

Genitourinary

Kidney Stones Yes No

Polycystic Kidney Disease Yes No

Frequent Urinary Tract Infections Yes No

Solitary Kidney Yes No

Prostate problems Yes No

Do you see a urologist? Yes No

If so, who? _____________________________________


Musculoskeletal

Gout Yes No Osteoporosis Yes No

Osteoarthritis Yes No Scoliosis Yes No

Back/Spinal Injury Yes No

Neurological

Stroke Yes No Parkinson’s Yes No

Neuropathy Yes No Dementia Yes No

Seizures Yes No Memory Issues Yes No

Do you see a Neurologist? Yes No If so, who? _______________________

Psychiatric

Depression Yes No Anxiety Disorder Yes No

Endocrine

Hypothyroidism Yes No Hyperthyroidism Yes No

Hyperparathyroidism Yes No Adrenal Insufficiency Yes No

Obesity Yes No

Do you see an endocrinologist? Yes No

If so, who? _______________________________________________________________________

Hematology

Cancer Yes No

If yes, type? _____________________________________ Year _________________________

Treatment type ______________________________________________________________________

Sickle Cell Trait Yes No Sickle Cell Disease Yes No

Blood Transfusion Yes No Thalassemia Yes No

Anemia Yes No Blood Doctor? __________________________

Autoimmune

Lupus Yes No Rheumatoid Arthritis Yes No

Multiple Sclerosis Yes No Vasculitis Yes No

Do you see a Rheumatologist? Yes No

If so, who? _________________________________________________________________

HIV/AIDS Yes No When diagnosed? ___________________

If so, on medication? Yes No Who manages? ________________________

Miscellaneous

Chronic Pain Yes No

If yes, who manages? ________________________________________________________________

Functional Disability Yes No Mental Disability Yes No


Additional Medical History

Surgical History

Appendectomy Yes No Hysterectomy Yes No

CABG Yes No Nephrectomy Yes No

Carotid Yes No Cardiac Valve Yes No Endarterectomy Replacement

Thyroidectomy Yes No D&C / C-Section Yes No

Tonsillectomy Yes No Gallbladder Removal Yes No

Cataract Surgery Yes No Gastric Bypass Yes No

AV Fistula Yes No Hemorrhoidectomy Yes No

AV Graft Yes No Hernia Repair Yes No

PD Catheter Yes No Hip Replacement Yes No

Knee Replacement Yes No Other:

Father Mother Sister Brother








Family History

Kidney Disease

High Blood Pressure

Heart Disease

Diabetes

Cancer

Stroke

Gout

Autosomal Dominant Polycystic

Kidney Disease

Dementia

Autoimmune disorder


Father Living Age: ______________ Deceased Age: ________________

Mother Living Age: ______________ Deceased Age: ________________




Social History

Marital Status Married Single Separated

Widowed Divorced

Living Arrangement Alone Spouse

Family Member In-home Caregiver

Assisted Living Name: _____________________________

Nursing Home Name: _____________________________

Occupation Retired Previous Occupation: _______________________

Employed Current Occupation: _______________________

Student Unemployed

Functional/ None Memory Deficit Hearing Loss Cognitive

Poor vision Blindness Limited Mobility

Transportation Challenges

Habits Never Former Current Amount

Tobacco Cigarettes _________

Pipes _________

Snuff _________

Cigars _________

Chew _________

Alcohol < 1 Week

1 per week

2-3 per week

1 per day

> 1 per day

Recreational Drug Use Never Former Current

Marijuana

Heroin

Cocaine

Amphetamines

Ecstasy

Barbiturates

LSD

Opium

Other


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MEDICAL HISTORY · MEDICAL HISTORY Please mark YES or NO and fill in appropriate blanks as needed Kidney Disease Chronic Kidney Disease Yes No If yes, year diagnosed _____ Previous